Long-term strategies to control COVID-19 in low and middle-income countries: an options overview of community-based, non-pharmacological interventions

Abstract

In low and middle-income countries (LMICs), strict social distancing measures (e.g., nationwide lockdown) in response to the COVID-19 pandemic are unsustainable in the long-term due to knock-on socioeconomic and psychological effects. However, an optimal epidemiology-focused strategy for 'safe-reopening' (i.e., balancing between the economic and health consequences) remain unclear, particularly given the suboptimal disease surveillance and diagnostic infrastructure in these settings. As the lockdown is now being relaxed in many LMICs, in this paper, we have (1) conducted an epidemiology-based "options appraisal" of various available non-pharmacological intervention options that can be employed to safely lift the lockdowns (namely, sustained mitigation, zonal lockdown and rolling lockdown strategies), and (2) propose suitable application , prerequisites , and inherent limitations for each measure. Among these, a sustained mitigation-only approach (adopted in many high-income countries) may not be feasible in most LMIC settings given the absence of nationwide population surveillance , generalised testing, contact tracing and critical care infrastructure needed to tackle the likely resurgence of infections. By contrast, zonal or local lockdowns may be suitable for some countries where systematic identification of new outbreak clusters in real-time would be feasible. This requires a generalised testing and surveillance structure, and a well-thought out (and executed) zone management plan. Finally, an intermittent, rolling lockdown strategy has recently been suggested by the World Health Organization as a potential strategy to get the epidemic under control in some LMI settings, where gener-alised mitigation and zonal containment is unfeasible. This strategy, however, needs to be carefully considered for economic costs and necessary supply chain reforms. In conclusion, while we propose three community-based, non-pharmacological options for LMICs, a suitable measure should be context-specific and based on: (1) epidemiological considerations, (2) social and economic costs, (3) existing health systems capabilities and (4) future-proof plans to implement and sustain the strategy.

Full text

Vol.:(0123456789)
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European Journal of Epidemiology (2020) 35:743–748
https://doi.org/10.1007/s10654-020-00660-1
COVID-19
Long‑term strategies tocontrol COVID‑19 inlow
andmiddle‑income countries: anoptions overviewof
community‑based,non‑pharmacological interventions
RajivChowdhury1 · ShammiLuhar1· NusratKhan1· SohelRezaChoudhury2· ImranMatin3· OscarH.Franco4
Received: 14 June 2020 / Accepted: 1 July 2020 / Published online: 13 July 2020
© The Author(s) 2020
Abstract
In low and middle-income countries (LMICs), strict social distancing measures (e.g., nationwide lockdown) in response
to the COVID-19 pandemic are unsustainable in the long-term due to knock-on socioeconomic and psychological effects.
However, an optimal epidemiology-focused strategy for ‘safe-reopening’ (i.e., balancing between the economic and health
consequences) remain unclear, particularly given the suboptimal disease surveillance and diagnostic infrastructure in these
settings. As the lockdown is now being relaxed in many LMICs, in this paper, we have (1) conducted an epidemiology-based
“options appraisal” of various available non-pharmacological intervention options that can be employed to safely lift the
lockdowns (namely, sustained mitigation, zonal lockdown and rolling lockdown strategies), and (2) propose suitable applica-
tion, pre-requisites, and inherent limitations for each measure. Among these, a sustained mitigation-only approach (adopted in
many high-income countries) may not be feasible in most LMIC settings given the absence of nationwide population surveil-
lance, generalised testing, contact tracing and critical care infrastructure needed to tackle the likely resurgence of infections.
By contrast, zonal or locallockdowns may be suitable for some countries where systematic identification of new outbreak
clusters in real-time would be feasible. This requires a generalised testing and surveillance structure, and a well-thought out
(and executed) zone management plan. Finally, an intermittent, rolling lockdown strategy has recently been suggested by
the World Health Organization as a potential strategy to get the epidemic under control in some LMI settings, where gener-
alised mitigation and zonal containment is unfeasible. This strategy, however, needs to be carefully considered for economic
costs and necessary supply chain reforms. In conclusion, while we propose threecommunity-based, non-pharmacological
optionsfor LMICs, a suitable measure should be context-specific and based on: (1)epidemiological considerations, (2)social
and economic costs, (3)existing health systems capabilities and (4)future-proof plans to implement and sustain the strategy.
Keywords COVID-19· Low and middle-income countries· Non-pharmacological interventions· Exit plan· Zonal
lockdown· Local lockdown· Rolling lockdown· Mitigation
Introduction
The coronavirus disease-2019 (COVID-19) pandemic has
claimed more than 500,000 lives worldwide [1] and has been
responsible for significant economic disruptions globally [2].
Similar to the high-income nations, low and middle-income
countries (LMICs) also responded to COVID-19 by imple-
menting various population-level measures, including strict
nationwide lockdowns and physical distancing [3]. World-
wide, with no effective treatments for COVID-19 and a vac-
cine at least a year away, these measures have been gener-
ally effective in preventing health systems from becoming
overloaded, especially in the LMICs where: (1) the risk of
disease transmission is high (populations are often large and
Rajiv Chowdhury, Shammi Luhar, and Nusrat Khan contributed
equally.
* Rajiv Chowdhury
rc436@medschl.cam.ac.uk
1 Department ofPublic Health andPrimary Care, School
ofClinical Medicine, University ofCambridge, Cambridge,
UnitedKingdom
2 Department ofEpidemiology, National Heart Foundation
Hospital andResearch Institute, Dhaka, Bangladesh
3 Brac Institute forGovernance andDevelopment, Brac
University, Dhaka, Bangladesh
4 Institute ofSocial andPreventive Medicine, University
ofBern, Bern, Switzerland
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

744 R.Chowdhury et al.
1 3
dense, with a high degree of interaction and physical con-
tact), (2) awareness of how to prevent disease is often poor
(eg, clean water and hygiene practices), (3) public health
systems are often under-resourced (eg, safety equipment and
intensive care units/ICU), and (4) access to healthcare is
limited and reliant on largely out-of-pocket payment.
These strict social distancing interventions, however,
come with a price: they are unsustainable in the long term
given their social, economic and psychological impacts.
For example, a recently completed survey in Bangladesh
showed that after its initial days of lockdown, a staggering
72% of urban and 54% of rural households had lost their
main source of earnings [4]. Therefore, many LMICs are
currently lifting the lockdowns, irrespective of the status of
infection and the level of contagion. It remains, however,
unclear what would be an optimal strategy for ‘safe re-open-
ing’ (given the likelihood of disease resurgence), especially
across low-income settings, where diagnostic capacities and
surveillance infrastructure is poor [5].
In this regard, we have considered three community-
based non-pharmacological strategies for LMICs (which aim
to strike a balance between health protection and prevent-
ing economic collapse) and propose appropriate application,
ideal pre-requisites, and inherent limitations for each. They
include: (1) sustained mitigation, (2) zonal lockdown, (3)
rolling lockdown (dynamic measures). These strategies (as
summarized in Fig.1) should not be considered as mutu-
ally exclusive, and could be further adapted and combined
depending on local disease epidemiology and socioeco-
nomic circumstances.
Sustained mitigation
Following theinitial national lockdowns, staying on a ‘mit-
igation-only’ phase (a strategy adopted by developed coun-
tries such as France, Switzerland and Italy) has involved
measures such as physical distancing, wearing masks, test-
trace-isolation of suspected cases, shielding of the vulner-
able and banning mass gatherings [6]. The successful imple-
mentation of this no-lockdown mitigation-onlyapproach,
however, is contingent on a number of key factors.
First, the implementation of the earlier strict lockdown
has resulted in a significant reduction of contact rates, new
infections, and case fatality in the country [7, 8]. In this
regard, somewhat worryingly, many LMICs, where lock-
down has recently been lifted, appear to have an upward
trend of cases and deaths [9]. Second, there isavailability of
nationwide surveillance, mass testingoperations and rapid
case isolation to tackle any resurgence and tofacilitate con-
tainment [10, 11]. Third, for contact-tracing, enough trained
contact tracers (or scalable digital platforms)are available,
with a relatively sparse target population (minimising the
possibility of super-spreading events). In this regard, the
effectiveness of contact-tracing might be importantly mini-
mised in large, dense countries such as Bangladesh (~ 1300
people/sqkm), compared to sparsely populated countries
like Spain (~ 90 people/sqkm) [12]. Contact-tracing is also
less effective at the height of community spread when the
rates are on the rise. Fourth, individual and population-level
adherence to mitigation measures (eg, physical distanc-
ing, hygiene, home quarantine)will be ensured. For many
LMICs, however,this remains a challenge given large-scale
social stigma and suboptimal risk communication strategies
[13]. Finally, healthcare services must be able to adequately
cope with the resurgence in new cases, including availability
of specialised care, hospitals and ICU beds. In many LMICs,
there is however a chronic shortage of (1) critical care infra-
structure (only 48,000 ventilators are available in India to
serve its 1.3 billion people [14]), (2) personal protective
equipment (PPE), (3) training of health workforce, and
(4) good working conditions—all of which reduce system
efficiency and enhance likelihood of transmission among
healthcare workers.
Despite being farless restrictive than afull lockdown,
a mitigation-only strategy is alsonot immune to financial
hardship as it can lead to somesocioeconomic disrup-
tion(e.g., reduced production due to workplace social dis-
tancing) – somewhat compromising its sustainability over
a prolonged period. For example, Sweden adopted some of
the most liberal mitigation measuresin the world such as
keeping restaurants, bars, and gyms open throughout the
previous few months, whilst encouraging physical distancing
rules. However, the countryis stillexpected to suffer ~ 10%
contraction in its economy in 2020 according to the Swedish
Central Bank [15].
Zonal lockdown
The idea of fencing between infected and healthy communi-
ties, termed cordon sanitaire, has been deployed during a
variety of outbreaks for centuries. In line with this principle,
as an exit strategy, many countries have transitioned to a sys-
tem of “zonal (or local)lockdown” [16]. This system entails
identification of specific “hotspots” where a sudden outbreak
cluster, with a high number of cases, have been identified in
real time. Such clustered social distancing works by dividing
the population into “zones” according to the geospatial dis-
tribution of disease cluster contained within, so that interac-
tions within a zone are significantly greater than interactions
between zones [17]. Transmission hotspots, or “red zones”
are subject to strict lockdown measures than “green zones”,
where very few or no new cases have been identified for
several days. Such strategies were adopted in France [17],
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745
Long-term strategies tocontrol COVID-19 inlow andmiddle-income countries: anoptions overview…
1 3
Fig. 1 A visual summary of the three proposed community-based non-pharamacological option for developing countries
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

746 R.Chowdhury et al.
1 3
with green zones defined by areas where the virus transmis-
sion is relatively low and there is not as burdensome pressure
placed on the healthcare system.
The “zonal lockdown” approach has several important
requirements. First, this categorisation of hotspots is typi-
cally a dynamic process, which requires an ability to reli-
ably identify, in real time, areas that meet or fall short of
the pre-specified lockdown criteria. This requires continu-
ous data-driven feedbacks on: (1) regional daily confirmed
cases (either by date of reporting or onset of symptoms),
and (2) other time-series information needed to calculate
the changes in region-specific effective reproduction number
(R, the average number of secondary infections per infected
individual), including daily numbers of hospitalized cases,
daily numbers of deaths in different age groups, and trans-
mission dynamics (eg, average time from infection to death)
[17]. While such strategy has been successfully established
in developed settings (such as France, where testing is wide-
spread with 0.52 daily tests being done per 1000 population),
this remains challenging in many LMICs due to (1) absence
of large-scale population surveillance system based on ran-
domly-selected individuals (e.g., in Bangladesh, the testing
approach has focused on purposive, self-referred samples,
with significant selection bias), and (2) poor testing labora-
tory facilities and reporting capacities (e.g., in Pakistan, only
0.09 daily tests are being conducted per 1000 individuals)
[18]. In this regard, India has adapted a scalable mass "Pool
testing" approach [19]. This cost-effective strategy involves
collecting multiple samples in a tube and testing them with
a single RT-PCR assay run. If the test is negative, all the
people tested are negative. If it is positive, every person has
to be tested individually for the virus. This approach reduces
the time needed to test large swathes of the population [20].
Second, the classification of the zones should also be
multifactorial. This should not only take into considera-
tion the incidence rate, but also the other epidemiological
(e.g., doubling rate of new cases; number of deaths) and
administrative aspects (e.g., available hospital and ICU
beds; testing and surveillance structure; residential versus
industrial zone). Third, managing the zones efficiently to
reduce transmission both within and outside of the zones
is a major undertaking. Recent reports from India shows
that infection size in many containment areas is 100-fold
to 200-fold higher than the cases reported at those sites—
indicating that containment efforts within zones may not
have fully paid off [21]. Therefore, detailed apriori standard
operating procedures should be devised to include aspects
on (1) within-zone public health measures (eg, risk commu-
nication, house-to-house surveillance, test booths, contact-
tracing, case referral systems, ambulance and medical facili-
ties), (2) within-zone measures of emergency services (eg,
food supply, law enforcement, isolation centres, and burial
facilities), and (3) outside-zone measures such as creation
of “buffer” zones (e.g., in India [19]) that surround the main
containment zone to minimise out-of-zone transmissions.
Such detailed protocols are crucial for efficiency. In Iran, for
example, suboptimal zone management has increased risk of
a second wave [22]. Finally, similar to sustained mitigation
strategy, the zonal lockdown will be most effective when
the overall rate of infection is in decline, accompanied by
exhaustive vigilance.
While zonal lockdown, if implemented properly, can help
contain the spread of the virus, efficacy of this approach
can be reduced by other concurrent transmission networks,
such as those linked to economic and social interdependency
between zones [17]. Additionally, the impacts on the econ-
omy, particularly inside the zones, can be considerably more
severe than under mitigation where the economy essentially
opens with restrictions, exacerbating economic hardship in
countries with already weak economic performance and
social security nets. Therefore, these aspects merit careful
consideration during the planning phase of this strategy.
Rolling lockdown
Intermittent or “rolling” lockdown measures take place when
strict social distancing measures are applied and lifted peri-
odically. This strategy has been described as a potentially
effective measure to minimise uncertainty in both effective
R values, and in the severity of the virus (i.e. the propor-
tion of cases requiring ICU admission) [23]. This approach
may be particularly suitable for the LMICs with large and
dense populations, high patterns of contact, poor economic/
health systems resilience, and weak testing/contact tracing
capacities. Furthermore, this approach addresses both key
elements of society that needs safe-keeping: life and liveli-
hood, and aims to provide a balance between avoiding public
health systems being overloaded and grinding economies
completely to a halt [24]. A recent paper mathematically
modelled the effects of either a strict 50-day suppression
or a 50-day mitigation, followed by 30days of relaxation
(during which businesses are allowed to reopen, with basic
hygiene measure kept in place), in 16 economically diverse
countries. In these models, a strict 50-day lockdown, that
reduces the effective R value to 0.5, prevented ICU beds
overload and led to considerably fewer deaths (130,000
during 18months in the 16 countries they modelled) com-
pared to a more relaxed 50-day mitigation/30-day relaxation
cycle (~ 3.5 million predicted deaths globally) and under no-
intervention (counter-factual) scenario (8 million predicted
deaths) [25]. To further contextualize the value of such con-
cept, a subsequent paper estimated that (1) a single, one-off
lockdown will be insufficient to bring the pandemic under
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747
Long-term strategies tocontrol COVID-19 inlow andmiddle-income countries: anoptions overview…
1 3
control, and (2) secondary peaks would be larger than the
first, without continued restrictions [26].
However, as with the other strategies, rolling lockdown
approach is also contingent on several factors. First, before
implementing a rolling lockdown, every developing country
should carefully consider the economic and social costs to
implement these measures. Second, impacts on incidence and
case-fatality will rely on local levels of adequate adherence
to social distancing measures. Third, this approach would
also bring a new set of logistical challenges. Therefore, coun-
tries will need to formulate bespoke plans for reorganising
business supply chains, so that they align with the economy
opening and closing. While such readjustments to comple-
ment a schedule of lockdown is not ideal, unprecedented
challenges often require unusual and adaptive solutions,
especially if other alternative exit strategies are not feasi-
ble. Finally, by establishing a detailed surveillance system
while the lockdown takes place, countries should adapt the
duration of the lockdown and relaxation periods according
to the local growth rate and pattern of the epidemic. A recent
example of this has been in Pakistan, where the World Health
Organization has recommended a 14-day-on/14-day-off roll-
ing lockdown to control the epidemic [27]. Similarly, rolling
lockdowns do not have to be generalised, these can also be
adapted as regional or zonal rolling lockdowns within a coun-
try, i.e., to apply specifically in areas with high and sustained
new-onset COVID-19 cases per population.For example,
zonal rolling lockdowns have been proposed in theGauteng
province of South Africa—one of the worst affected regions
in the country—to control the rapid increase in infection rates
[28].
Conclusion
While many LMI countries are currently lifting the lock-
downs due to economic reasons, it is crucial for the policy
makers to recognise that preserving health is equally impor-
tant for reviving the economy. This is of important relevance
to the LMICs where large proportions of working-age popu-
lation are vulnerable to adverse COVID-19 outcomes, owing
to high prevalence of comorbid conditions (such as diabetes,
obesity and hypertension) [29]. Furthermore, if a country
has constant high incidence of adeadly disease, it may
become rather challenging for the local economy to thrive
in such environment [30].Therefore, equal priorities must
be put on protecting lives as well as livelihood when adapt-
ing an exit plan. In this regard, we have proposedseveral
non-pharmacological strategies that may enable the LMICs
to safely open the economy, while allowing for preserva-
tion of health. However, it is crucial that theselection ofa
suitable, “context-specific” strategyis based on some key
considerations: (1) local epidemic growth rate, (2) existing
health infrastructure (to survey, test, and treat, at scale), (3)
social and economic costs, and (4) carefully-devised plans
to implement and sustain the measures.
Author contributions RC conceptualised the paper. RC, SL and NK
led the manuscript drafting. OHF, SRC and IM provided scientific and
technical comments to strategic options discussed in this manuscript.
RC, SL and NK did the necessary background literature review.IM
and RC produced the visual abstract. RC leads several COVID-19
projects and published COVID-19 modelling studies related to non-
pharmacological interventions. SL is an epidemiologist involved
with various Cambridge-led COVID-19 projects. NK is a clinician
and doctoral researcher in global public health involved with various
Cambridge-led COVID-19 projects. OHF is the Director of Institute
of Social and Preventive Medicine at the University of Bern, where
he advises various national (Switzerland) and regional (Latin Amer-
ica) COVID-19 technical response committees. SRC is a member of
COVID-19 Technical Response Committee in Bangladesh. IM is the
Executive Director of BRAC Institute of Global Development, leading
an ongoing BRAC-SOAS-Cambridge project to formulate an adaptive
and integrated framework for health responses to COVID-19 in the
developing countries.
Compliance with ethical standards
Conflict of interest None to declare.
Open Access This article is licensed under a Creative Commons Attri-
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permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/.
References
1. Worldometer. COVID-19 coronavirus pandemic. COVID-19 cor-
onavirus pandemic. 2020. https ://www.world omete rs.info/coron
aviru s/
2. Sterne G, Sleptsova E. Global Coronavirus Watch: EMs weigh
health vs economy. Research Briefing. 2020.http://blog.oxfor
decon omics .com/coron aviru s/ems-weigh -healt h-vs-econo my
3. Gopinath G. The great lockdown: worst economic downturn since
the great depression. IMF Blog (Global Economy). 2020.https ://
blogs .imf.org/2020/04/14/the-great -lockd own-worst -econo mic-
downt urn-since -the-great -depre ssion /
4. Banks N, Hulme D. Understanding the impacts of Covid-19 on
livelihoods in bangladesh: findings from the PPRC-BIGD rapid
response survey. University of Manchester Global Development
Institute Blog. 2020.http://blog.gdi.manch ester .ac.uk/under stand
ing-the-impac ts-of-covid -19-on-livel ihood s-in-bangl adesh /
5. Nsubuga P, White ME, Thacker SB, Anderson MA, Blount SB,
Broome CV, etal. Public health surveillance: a tool for target-
ing and monitoring interventions. In: Disease control priorities in
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

748 R.Chowdhury et al.
1 3
developing countries. Chapter53, 2nd edition. Washington (DC),
Oxford University Press, New York: The International Bank for
Reconstruction and Development/The World Bank. 2006. https ://
www.ncbi.nlm.nih.gov/books /NBK11 770/
6. Walensky RP, del Rio C. From mitigation to containment of the
COVID-19 pandemic: Putting the SARS-CoV-2 genie back in the
bottle. JAMA. 2020;323(19):1889–1890
7. Wilder-Smith A, Freedman DO. Isolation, quarantine, social dis-
tancing and community containment: pivotal role for old-style
public health measures in the novel coronavirus (2019-nCoV) out-
break.J Travel Med. 2020;27(2):taaa020. https ://doi.org/10.1093/
jtm/taaa0 20
8. Lau H, Khosrawipour V, Kocbach P, Mikolajczyk A, Schubert
J, Bania J, etal. The positive impact of lockdown in Wuhan
on containing the COVID-19 outbreak in China.J Travel Med.
2020;27(3):taaa037
9. Economist T. Infections are rising fast in Bangladesh, India and
Pakistan. The Economist. 2020. https ://www.econo mist.com/
asia/2020/06/06/infec tions -are-risin g-fast-in-bangl adesh -india
-and-pakis tan
10. Commission E. Coronavirus: a common approach for safe and
efficient mobile tracing apps across the EU, Brussels. 2020. https
://ec.europ a.eu/commi ssion /press corne r/detai l/en/qanda _20_869
11. Steinbrook R. Contact Tracing, Testing, and Control of COVID-
19-Learning From Taiwan.JAMA Intern Med. 2020 (in press).
12. United Nations, Department of Economic and Social Affairs,
Population Division. World Population Prospects 2019. 2019.
https ://popul ation .un.org/wpp/Downl oad/Stand ard/Popul ation /
13. Newagebd. Stigma around COVID-19 hampers the fight against
it. www.newag ebd.net. 2020. https ://www.newag ebd.net/artic
le/10570 1/stigm a-aroun d-covid -19-hampe rs-the-fight -again st-it
14. Kapoor G, Sriram A, Joshi J, Nandi A, Laxminarayan R. COVID-
19 in India: State-wise estimates of current hospital beds, inten-
sive care unit (ICU) beds and ventilators. The Center For Disease
Dynamics, Economics & Policy. 2020.https ://cddep .org/publi
catio ns/covid -19-in-india -state -wise-estim ates-of-curre nt-hospi
tal-beds-icu-beds-and-venti lator s/
15. Riksbank S. Monetary policy April 2020: The Riksbank is sup-
porting an economy in crisis. Stockholm. 2020. https ://www.
riksb ank.se/globa lasse ts/media /nyhet er--press medde lande n/press
medde lande n/2020/press -relea se-monet ary-polic y-april -2020-the-
riksb ank-is-suppo rting -an-econo my-in-crisi s.pdf
16. Mahase E. Covid-19: how does local lockdown work, and is it
effective? BMJ. 2020;370:m2679
17. Oliu-Barton M, Pradelski B, Attia L. Exit strategy: from self-
confinement to green zones.EsadeEcPol Insight (6). 2020. https
://www.esade .edu/items web/wi/resea r ch/ecpol /Esade EcPol _Insig
th6_Exit_Strat egy.pdf
18. Hasell J, Mathieu E, Beltekian D, Macdonald B, Giattino C, Ortiz-
Ospina E, etal. Statistics and research coronavirus (COVID-19)
testing. Our World in Data. 2020. https ://ourwo rldin data.org/coron
aviru s-testi ng#
19. MOHFW. Guideline for RT-PCR based pooled sampling for
migrants/returnees from abroad/green zones. 2020. https ://www.
mohfw .gov.in/pdf/Guide linef orrtP CRbas edpoo ledsa mplin gFina
l.pdf
20. MOHFW. Containment plan novel coronavirus disease 2019
(COVID 19) Version 2. 2020.https ://www.mohfw .gov.in/pdf/
Conta inmen tplan 16052 020.pdf
21. Dutta SS. 15–30% people in containment areas exposed to
COVID-19: ICMR’s serosurvey. The New Indian Express. 2020.
https ://www.newin diane xpres s.com/natio n/2020/jun/08/15-30-
peopl e-in-conta inmen t-areas -expos ed-to-covid -19-icmrs -seros
urvey -21538 93.html
22. BBC. Coronavirus: Iran fears second wave after surge in cases.
BBC News. 2020. https ://www.bbc.co.uk/news/world -middl
e-east-52903 443
23. Ferguson NM, Laydon D, Nedjati-Gilani G, Imai N, Ainslie K,
Baguelin M, etal. Impact of non-pharmaceutical interventions
(NPIs) to reduce COVID-19 mortality and healthcare demand.
Imperial College COVID-19 Response Team. 2020.https ://www.
imper ial.ac.uk/media /imper ial-colle ge/medic ine/sph/ide/gida-
fello wship s/Imper ial-Colle ge-COVID 19-NPI-model ling-16-03-
2020.pdf
24. Chowdhury R. Rolling lockdowns could protect both economies
and health in low-income countries. The Conversation. 2020. https
://theco nvers ation .com/rolli ng-lockd owns-could -prote ct-both-
econo mies-and-healt h-in-low-incom e-count ries-13905 4
25. Chowdhury R, Heng K, Shawon MSR, Goh G, Okonofua D,
Ochoa-Rosales C, etal. Dynamic interventions to control COVID-
19 pandemic: a multivariate prediction modelling study compar-
ing 16 worldwide countries. Eur J Epidemiol. 2020;35:389–99.
26. Kissler SM, Tedijanto C, Goldstein E, Grad YH, Lipsitch M. Pro-
jecting the transmission dynamics of SARS-CoV-2 through the
postpandemic period. Science. 2020;368(6493):860–8.
27. Farooq U, Peshimam G. WHO recommends Pakistan reimpose
intermittent lockdowns as COVID-19 cases rise sharply. The Reu-
ters. 2020. https ://www.reute rs.com/artic le/us-healt h-coron aviru
s-pakis tan-who/who-recom mends -pakis tan-reimp ose-inter mitte
nt-lockd owns-as-covid -19-cases -rise-sharp ly-idUSK BN23G 2ZJ
28. Nkanjeni U. Gauteng looking at ’intermittent’ lockdown as it
prepares for worst in Covid-19 cases. Sunday Times. 2020. https
://www.times live.co.za/news/south -afric a/2020-06-30-gaute ng-
looki ng-at-inter mitte nt-lockd own-as-it-prepa res-for-worst -in-
covid -19-cases /
29. Shuchman M. Low- and middle-income countries face up to
COVID-19. The Nature. 2020.https ://doi.org/10.1038/d4159
1-020-00020 -2.
30. Bodenstein M, Corsetti G, Guerrieri L.Social Distancing and
Supply Disruptions in a Pandemic.Cambridge Working Papers
in Economics.2020.https ://www.inet.econ.cam.ac.uk/worki ng-
paper -pdfs/wp201 7.pdf
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